Our patient was detected to have Twiddler's syndrome within 48 h of implantation. So far the earliest reported case is at 17 h. ,, Īlthough the majority of cases occur during the first year of implantation, a "late Twiddler's syndrome" has also been reported. Although originally described with pacemakers, the condition has also been reported with implantable cardioverter-defibrillators. Older literature suggests a subgroup of partial Twiddler's syndrome where capturing function is maintained. ,, Pacemaker lead displacement according to its position may produce failure to pace, diaphragmatic contraction by phrenic nerve stimulation, vagus nerve, pectoral muscle, or brachial plexus stimulation resulting in rhythmic arm twitching and finally may wrap around the pulse-generator as in our case. , Risk factors for this condition include elderly age group, obesity, female gender, psychiatric illness, and the small size of the implanted device relative to its pocket. The reported frequency of Twiddler's syndrome is around 0.07-7%. Postoperative hospital stay was uneventful and the patient was doing well in subsequent follow-ups. The pulse-generator was fixed on the pectoral muscle with nonabsorbable suture. Both the leads were found to have good sensing and pacing parameters. The old atrial lead was repositioned with an appropriate loop. A new active fixation screwing ventricular lead was inserted. The pacemaker pocket was immediately reopened. The temporary pacemaker lead can also be identified lower down The atrial lead can also be tracedįigure 2: The atrial lead is shown to be in position, although the loop originally kept was reduced significantly. The patient denied any manipulation of the pulse-generator.įigure 1: Fluoroscopic image showing the pulse-generator with twisted ventricular lead around it. A diagnosis of pacemaker Twiddler's syndrome was made. The atrial lead was seen to be in position but the initial loop was drastically reduced. Fluoroscopy clearly showed the pulse-generator with twisted ventricular lead around it. The patient was immediately rushed to the pacing laboratory where a prophylactic temporary pacemaker was inserted. Pacemaker interrogation showed complete loss of pacing and sensing in ventricular lead with intact atrial lead function. An ECG also corroborated proper functioning of the DDDR system.ĭuring the postoperative hospital stay, a routine chest skyagram on 2 nd day revealed dislodgment of ventricular lead. Postoperative fluoroscopic images confirmed the satisfactory positioning of both the atrial and ventricular leads. The implantation procedure was uneventful. Atrial lead P wave, threshold, and lead impedance were 3.5 mV, 0.5 V, and 590 ohm, respectively. Measured ventricular lead R wave, threshold and lead impedance were 14 mV, 0.5 V, and 640 ohm, respectively. A DDDR (dual chamber rate adaptive pacemaker) system was implanted in the right prepectoral area with a bipolar passive fixation ventricular lead and an active fixation bipolar screwing atrial lead at right atrial appendage. Baseline electrocardiogram (ECG) revealed complete RBBB (right bundle branch block) with left axis deviation. In this report we present a patient who was diagnosed with Twiddler's syndrome within 48 hours of implantation of the permanent pacemaker.Ī 66-year-old post-CABG (coronary artery bypass grafting), nondiabetic, nonhypertensive, male patient with good left ventricular systolic function (ejection fraction 60%) was admitted with symptomatic intermittent complete heart block. The majority of patients with this condition are diagnosed within the first year of implant. In this syndrome there is painless dislodgment of device leads resulting from the patient's manipulation of the implanted device. Twiddler's syndrome, first described by Bayliss in 1968, is a rare but potentially lethal complication of pacemaker treatment. A rare case of very early pacemaker Twiddler's syndrome. How to cite this URL: Mandal S, Pande A, Kahali D. How to cite this article: Mandal S, Pande A, Kahali D. Keywords: Pacemaker, Twiddler′ syndrome, Pacing leads Active fixations fixations of device leads are very much essential to prevent this catastrophic complication. In our case, passive fixation of ventricular lead perpetuated this situation and subsequent active fixation prevented any recurrence. In this report we present a patient who was diagnosed Twiddler's syndrome within the initial 48 h of implantation of permanent pacemaker. It is characterized by device malfunction due to dislodgement of cardiac leads resulting from some form of manipulation by the patient. Twiddler's syndrome, a rare but potentially lethal complication of cardiac pacemaker treatment, is generally diagnosed within the first year of implantation.
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